‘Crystal’ in the heart

Abstract

A 35-year-old man presented to the emergency unit with progressive dyspnoea of two weeks’ duration. He had no previous medical history, and denied chest discomfort. During echocardiography, a severely impaired biventricular systolic function with severe atrioventricular valve insufficiency was found. The left ventricular end diastolic diameter (LVEDD) was 74 mm (Fig. 1A). There was no evidence of coronary artery disease (CAD), as shown in Figure 1B. On inquiry, he confessed to a weekly consumption of ‘crystal’ (methyl amphetamine) of about 0.5–1 g. Haemodynamic findings showed a decreased cardiac index of 1.7 L/min/m2. The patient had an intra-aortic balloon pump implanted as a bridge to recovery. However, haemodynamic and echocardiographic parameters did not improve, so he received a levosimendan infusion. Left ventricular endomyocardial biopsies were taken, and histological and immunohistological examinations revealed severe methamphetamine-induced chronic myocardial injury with degeneration of hypertrophied myocytes neighbouring small arterioles with medial hyperplasie in the presence of a mild inflammatory reaction (Fig. 1D). There was no evidence of acute or chronic myocarditis, amyloidosis or preexisting dilated or other primary cardiomyopathies. No viral genomes were detected by nested PCR analysis. The results were confirmed by cardiac magnetic resonance imaging (MRI) (Fig. 1C). Late gadolinium enhancement indicating myocardial fibrosis or necrosis was not obvious. The patient slowly recovered over the course of two weeks. Long-term ECG showed a non-sustained ventricular tachycardia of 18 beats. He left hospital with a wearable cardioverter-defibrillator (LifeVest®). Chronic use of methyl amphetamine may result in severe heart failure, malnutrition, infections and permanent psychiatric illness. The patient was discharged for outpatient drug rehabilitation.